AB0885 Refractory chronic synovitis of the common flexor synovial sheath in Psoriatic arthritis patient successfully treated by ultrasound guided local Methotrexate injection.
Authors: A. Abogamal
Journal: Annals of the Rheumatic Diseases (2022)

Background Psoriatic arthritis (PsA) is a variant of inflammatory musculoskeletal conditions that usually associated with skin psoriasis. PsA is typically heterogenous in comparison to other rheumatic diseases, It affects multiple musculoskeletal domains including synovitis of peripheral and axial joints, entheses, and tendons with tenosynovitis. [1,2] Persistent cases of arthritis or tenosynovitis usually controlled by local injection with corticosteroids, though some refractory cases of chronic synovitis still not sufficiently controlled by corticosteroid local injection with some case series shows a significant response to local DMARDs and even local Biologics. [3-6] Objectives To describe a case of psoriatic arthritis with chronic synovitis of the common flexor synovial sheath successfully treated by ultrasound guided local Methotrexate injection. Methods 31 Years old female with psoriatic arthritis in the form of symmetrical hand arthritis for the last 10 years, and extensive nail disease shows partial control under treatment with Methotrexate after failure of sulfasalazine. Her DAPSA score usually ranges between 16 to 18 with tender persistent fluctuating cystic swelling overlying her right palm extending proximally to the distal third of the forearm that becomes more tens on fingers flexion. Ultrasound examination shows hypoechoic distension of the right common flexor synovial sheath, that is partially compressible and partially displaceable with highly positive Doppler signals indicating active synovitis. Figure 1 Figure 1. palmar longitudinal ultrasound scan over the radio-carpal region, A: Synovitis with effusion in the common flexor Sheath, B: Positive Color Doppler denoting active synovitis, C: Follow up ultrasound scan showing resolution of synovitis and effusion. October 2019, ultrasound guided aspiration and local corticosteroid injection applied for the common flexor sheath with escalation of her treatment to Ixekizumab plus Methotrexate to achieve clinical remission. January 2020, patient achieve DAPSA 8 with resolution of have nail lesions, though her right hand function was still significantly impaired due to the refractory persistent synovitis of the Common flexor sheath. Two doses 15mg Methotrexate one week apart inserted into the common flexor sheath under ultrasound imaging. Results April 2020, on regular follow up patient achieve DAPSA remission &lt;4, with complete resolution of the right palm swelling and she reports complete recovery of her hand function which is maintained up to January 2022 in her last follow up visit. Follow up ultrasound scan shows normalization of the common flexor sheath with disappearance of the mixed picture of synovitis and effusion. Figure 1 Conclusion Refractory synovitis of the common flexor sheath in PsA successfully treated with ultrasound guided local methotrexate injection with persistence of improvement for one year. References [1]Mease PJ. Psoriatic arthritis: update on pathophysiology, assessment and management. Ann Rheum Dis 2011;70 Suppl 1:i77–84. [2]Wilson FC, Icen M, Crowson CS, et al.: Incidence and clinical predictors of psoriatic arthritis in patients with psoriasis: A population-based study. Arthritis Rheum. 2009;61(2):233–9. [3]Fisher BA, Keat A. Should we be using intraarticular tumor necrosis factor blockade in inflammatory monoarthritis? J Rheumatol. 2006; 33 (10):1934–1935. [4]Marks JS, Stewart IM, Hunter JA. Intra-articular methotrexate in rheumatoid arthritis. Lancet. 1976; 2 (7990):857–858. [5]Hall GH, Jones BJ, Head AC, Jones VE. Intra-articular methotrexate. Clinical and laboratory study in rheumatoid and psoriatic arthritis. Ann Rheum Dis. 1978; 37 (4):351–356. [6]Mortada MA, Abdelwhab SM, Elgawish MH. Intra-articular methotrexate versus corticosteroid injections in medium-sized joints of rheumatoid arthritis patients-an intervention study. Clin Rheumatol. 2018; 37 (2):331–337. Acknowledgements Arlyn Acenas Disclosure of Interests None declared